HospitalInspections.org

Based on staff interview and review of medical records, hospital policies, organizational chart, contracts, personnel records, incident reports, Medical Staff Bylaws, QAPI documents, and meeting minutes, it was determined the hospital's Governing Board failed to assume responsibility for determining, implementing, and monitoring policies, and failed to oversee the hospital's nursing services. This resulted in a lack of leadership and guidance to hospital staff. Findings include:

1. The Governing Body failed to utilize a DON to oversee nursing services.

An organization chart, not dated, showed various departments of the hospital and listed the name of the department director. The box for Nursing Services did not list a director.

The Division President for the Mid-Mountain Region was listed directly under the Governing Board on the organization chart. He was a corporate vice-president who lived in another state. He was interviewed by telephone on 9/05/18 beginning at 11:00 AM. He stated he was Chairman of the Board for the hospital.

The Division President stated the hospital did not have a DON and said it was not the hospital's model to employ a DON. He stated the hospital had a Chief Clinical Officer who was a respiratory therapist. He stated she had oversight of the nursing services in the hospital.

The CEO was interviewed on 9/05/18 at 2:05 PM. She stated the hospital did not have a DON.

The Governing Body did not employ a DON.

2. The Governing Body failed to ensure guidelines were developed for Medical Staff call.

Vibra Hospital is a 40 bed long term acute care hospital. It accepts patients who are often very ill and fragile, such as patients on ventilators.

The hospital did not have onsite 24 hour physician coverage. The hospital maintained a practitioner call schedule in case patients had care needs after hours.

Medical Staff rules and regulations did not provide direction to practitioners who were on call, including the expectations and availability of practitioners to come to the hospital to evaluate patients.

The past President of the Medical Staff was interviewed on 9/05/18 beginning at 12:20 PM. He stated he was not aware of a rule or policy that defined the duties of practitioners on call.

The Governing Body did not develop guidance for the Medical Staff.

3. Refer to A84 as it relates to the failure of the Governing Body to ensure contracted nursing services were provided in an effective manner.

4. Refer to A115 as it relates to the failure of the Governing Body to ensure the rights of patients were protected and promoted.

5. Refer to A385 as it relates to the failure of the hospital to ensure nursing services were organized and supervised to effectively meet the health care needs of patients.

Based on staff interview and review of hospital policy, Governing Body meeting minutes, grievance log, patients rights information, incident report, grievance response letter, Idaho Statutes, medical record, observation, personnel file, and quality improvement document, it was determined the hospital failed to ensure patients' rights were protected and promoted. This resulted in an incomplete investigation, analysis, and recommendations following a patient death and had the potential to affect all patients receiving care at the hospital. Additionally, this resulted in a lack of an effective grievance process and Governing Body oversight, the identification of potential patient abuse, and the accuracy of a QIO for patients and/or their representatives to submit concerns regarding care rendered. Findings include:

1. Refer to A119 as it relates to the failure of the hospital to ensure the effective operation and oversight of the grievance process by the Governing Body.

2. Refer to A120 as it relates to the failure of the hospital to ensure an accurate process for referral of patient care concerns to a QIO.

3. Refer to A123 as it relates to the failure of the hospital to ensure written grievance resolutions which included all results of the grievance process.

4. Refer to A144 as it relates to the failure of the hospital to ensure care was provided in a safe manner.

5. Refer to A145 as it relates to the failure of the hospital to ensure patients were free from abuse or harassment.

The cumulative effects of these systemic practices seriously impeded the ability of the hospital to protect patient rights and provide services in a safe setting.

Based on observation, staff interview, and review of medical records, hospital documents, job descriptions, personnel files, contracts, and hospital policies, it was determined the hospital failed to ensure nursing services were organized and supervised to effectively meet the health care needs of patients. This resulted in a lack of direction and oversight of nurses at the hospital. Findings include:

1. Refer to A386 as it relates to the failure of the facility to ensure nursing services were organized under the authority of a director of nursing services responsible for nursing staff and care provided in the hospital.

2. Refer to A395 as it relates to the failure of the hospital to ensure nursing care provided by LPNs was evaluated and supervised by an RN.

3. Refer to A398 as it relates to the failure of the hospital to ensure orientation and training of non-employee contracted nursing personnel.

4. Refer to A405 as it relates to the failure of the hospital to ensure medications were administered in accordance with accepted standards of practice.

The cumulative effects of these systemic failures significantly impeded the ability of the hospital to provide nursing services of sufficient scope and quality.

Based on review of contracts, hospital policy, hospital documents, personnel records, and staff interview, it was determined the hospital failed to ensure contracted nursing services were provided in an effective manner. This resulted in the inability of the hospital to ensure contracted nurses were competent to perform their jobs. Findings include:

The hospital's policy, "Volunteer, Student Observers, Interns, Externs, Per Diem, and Contracted Services," revised 3/12/18, stated "Contracted Services...Orientation

a. All contracted personnel are required to complete the Hospital orientation packet to ensure a through [sic] understanding of expectations, hospital policies, safety and infection control.
b. Department orientation will address patient care issues and departmental policies and procedures.
c. The Department Director remains responsible for the oversight of the contracted personnel."

The hospital's "Daily Staffing Assignment" sheets for 7 days, from 8/30/18 to 9/05/18, were reviewed for the number of RNs on the night shift (7:00 PM to 7:30 AM) who were hospital employees verses contracted staff. On 6 of the 7 nights, the RN supervisor was a contracted RN. Ten of 40 RN shifts, or 25%, were completed by contracted RN staff.

A contract titled "Travel Personnel Staffing Agreement" signed by the hospital's CEO on 1/26/17, stated "Hospital shall orientate all Nurses to Hospital's internal policies and practices. Such orientation shall include information necessary to orientate each Nurse to the particular unit he/she has been assigned."

The personnel files of 2 RNs contracted through the travel agency were reviewed, with start dates of 4/30/18 and 5/28/18 . They did not include documentation of an orientation to the hospital's policies and procedures, or a department orientation.

A contract titled "STAFFING AGREEMENT" signed by the hospital's CEO on 6/17/16, stated "Facility shall provide such orientation and non-job specific training (such as training regarding Facility's employment policies) as is reasonably required by facility."

The personnel files of 2 RNs contracted through the staffing agency were reviewed, with start dates of 5/09/17 and 12/07/17. They did not include documentation of an orientation to the hospital's policies and procedure, or a department orientation.

During an interview on 9/05/18 at 4:05 PM, the VP of Clinical Development and Operations reviewed the personnel files of the 4 contracted RNs. She confirmed the 4 files did not include documentation of an orientation to the hospital's policies and procedures, or a department orientation.

The hospital failed to ensure RNs working in the hospital under contract received education on the hospital's policies and procedures, or orientation to the department.

0......................................................................................................................................................................................................Based on staff interview and review of hospital policy, grievance log, and Governing Body meeting minutes, it was determined the hospital failed to ensure the effective operation and oversight of the grievance process by the Governing Body for 6 of 9 patient grievances reviewed. This resulted in a lack of an effective grievance process and had the potential to affect all patients who received care in the hospital. Findings include:

The Governing Body failed to be responsible for the effective operation of the grievance process. Examples include:

1. The hospital "Complaint/Grievance Log 2018," dated 2/20/17 to 7/19/18, was reviewed. The log included 9 grievances, however, 6 of these were documented as complaints:

- Allegation of patient abuse dated 4/18/17 [incident 15277]. Required further investigation and actions for a postponed resolution. Documented as a patient complaint.

- Multiple patient family issues dated 5/10/17 [incident 3801336]. Required further investigation and actions for a postponed resolution. Documented as a patient complaint.

- Allegation of patient abuse dated 2/20/18 [incident 15584]. Required further investigation and actions for a postponed resolution. Documented as a patient complaint.

- Multiple patient family issues dated 3/09/18 [incident 15263]. Required further investigation and actions for a postponed resolution. Documented as a patient complaint.

- Multiple patient family issues dated 3/14/18 [incident "Pt. Spouse"]. Required further investigation and actions for a postponed resolution. Documented as a patient complaint.

- Multiple patient issues dated 7/19/18 [incident 15749]. Required further investigation and actions for a postponed resolution. Documented as a patient complaint.

A hospital policy "Patient Complaint and Grievance Process," reviewed January 2018, stated "Patient complaint: Concern/Dissatisfaction - A verbal expression of concern or dissatisfaction with a service or department within Vibra Hospital, that is more substantive than a minor request, and is resolved by the staff present, to the satisfaction of the complainant, on the departmental level at the point of the complaint. Patient complaint: Grievance - Any expression of dissatisfaction (written or verbal) related to an occurrence within Vibra Hospital of Boise which is of such severity that it is not able to be resolved to the satisfaction of the complainant at a departmental level by the staff present. Complaints that require further investigation, further actions for resolution, or are postponed for later resolution are considered grievances." Hospital staff were unable to differentiate the difference between a patient complaint and a patient grievance. Examples include:

a. RN A was interviewed on 8/31/18, beginning at 8:51 AM. When asked for her definition of a patient complaint, she stated "complaints can be resolved in-house; if a complaint is still in-house and works its way up the chain-of-command, it is still a complaint." When asked for her definition of a patient grievance, RN A stated "a complaint with no resolution after the patient discharges or is unhappy; the grievance must be formal."

b. RN B was interviewed on 8/31/18, beginning at 9:13 AM. When asked for her definition of a patient complaint, she stated "something a patient would say to me for me to fix; if I can't resolve, it would go to the House Supervisor, but would still remain a complaint." When asked for her definition of a patient grievance, RN B stated "it's a formal process that would go up the chain-of-command."

c. HS A was interviewed on 8/31/18, beginning at 9:21 AM. When asked for his definition of a patient complaint, he stated "something that is addressed right away; a written complaint is still a complaint." When asked for his definition of a patient grievance, HS A was unsure. He stated "unsure if a grievance can be verbal, but it would be documented in the patient's chart and an incident report would be done." HS A stated he could not think of an example of a patient grievance.

d. The CCO was interviewed on 8/31/18, beginning at 9:32 AM. When asked for her definition of a patient complaint, she stated "it's dealt with internally, during the same shift, or something longer." When asked for her definition of a patient grievance, the CCO stated "something that is a long formal process."

e. The NP was interviewed on 9/04/18, beginning at 11:12 AM. When asked for his definition of a patient complaint, he stated "I would talk to the House Supervisor about it or go to the appropriate Department if there was a complaint; a complaint can still be something another department handles." When asked for his definition of a patient grievance, the NP stated "a grievance is an official written report."

f. MT B was interviewed on 9/05/18, beginning at 9:26 AM. When asked for her definition of a patient complaint, she stated "a complaint is something that is escalated." When asked for her definition of a patient grievance, MT B stated "a grievance is something I can fix."

The Director of Quality Management was interviewed on 9/05/18, beginning at 2:03 PM, and the hospital's grievance log was reviewed in her presence. She confirmed staff did not have a consistent understanding or ability to identify patient grievances. The Director of Quality Management confirmed the hospital failed to recognize documented patient complaints as patient grievances.

Hospital staff were unable to differentiate and identify patient complaints from patient grievances.

2. The hospital's "Annual Governing Body Meeting Minutes," dated 4/05/18, were reviewed. The meeting minutes did not include documented review or resolution of patient grievances. Additionally, the meeting minutes did not document if the hospital had a grievance committee, delegated by the Governing Body, to review and resolve patient grievances. It was unclear how the Governing Body was providing oversight of the hospital's grievance process.

The Director of Quality Management was interviewed on 9/05/18, beginning at 2:03 PM. She confirmed the hospital did not have a Governing Body delegated grievance committee. The Director of Quality Management stated the hospital's grievance data was presented to the Governing Body by way of QAPI reporting. She confirmed the Governing Body did not review and resolve patient grievances.

The Governing Body failed to review and resolve patient grievances.

Based on hospital policy review, patients rights information review, and staff interview, it was determined the hospital failed to ensure an accurate process for referral of patient care concerns to a QIO for 8 of 8 patients (#'s 1 - 8) whose patients rights information was reviewed. This had the potential for unresolved patient issues regarding patients' quality of care and/or premature discharge. Findings include:

A hospital policy "Patient Complaint and Grievance Process," reviewed January 2018, stated "In the event the grievance is related to quality of care or premature discharge, the patient/family is advised they may contact Qualis Health, the Quality Improvement Organization for Idaho as per information provided on admission to the facility."

The patients rights form, "AN IMPORTANT MESSAGE FROM MEDICARE About Your Rights," included in Patient #'s 1 - 8's admission packets, stated "Report any concerns you have about the quality of care you receive to the Quality Improvement Organization (QIO) listed here: Livanta, LLC." The QIO listed in the patients rights information was not the same as the QIO listed on hospital policy. It was unclear who patients or their representatives should contact in the event they had concerns about their hospital care and/or premature discharge.

The Director of Quality Management was interviewed on 9/05/18, beginning at 2:03 PM, and patients rights were reviewed in her presence. She confirmed the QIO listed on hospital policy did not match the QIO given to patients in their admission packets.

The hospital failed to ensure an accurate process for referral of patient care concerns to a QIO.

Based on staff interview and review of hospital policy, incident report, and grievance response letter, it was determined the hospital failed to provide written grievance resolutions which included all results of the grievance process for 1 of 1 grievance resolution letters reviewed. This had the potential for incomplete grievance investigations and resolutions to patient/family concerns. Findings include:

A hospital policy "Patient Complaint and Grievance Process," reviewed January 2018, stated "Written notice of grievance resolution and decisions made is provided to complainants and contains the following...Steps taken on behalf of the patient to investigate the grievance...Results of the grievance process." This policy was not followed.

Incident report 45626, dated 1/02/18, included 7 patient grievance issues:

- "Spouse Reports the nebulizer hose that was attaches [sic] to the vent tubing popped off several times and the spouse has to place it back on and no one checks to make sure it was done correctly."

- "He [spouse] reported the hose fell on the floor last week and the attending nurse/RT (he was unable to identify) picked it up off the floor and reattached it without cleaning it."

- "He [spouse] said his wife is scared and feels unsafe."

- "They [patient and spouse] reported the patient was left alone with no call light in her reach this morning rather it was placed on top of the ventilator machine out of her reach."

- "He [spouse] reports the patient is turned and the lines are pulled tight and tubes sometimes get detached-he [sic] states the alarms are always going off and it is frightening and no one comes urgently to help."

- "The spouse reported the staff argue with him and the patient rather than try to help."

- "The patient is concerned she now has ecoli [sic] in the urine and feels it is because she does not get good hygiene care around her foley."

A written grievance response letter to incident report 45626, dated 1/05/18, did not include an investigation and results for 3 of the 7 identified issues:

- "Spouse Reports the nebulizer hose that was attaches [sic] to the vent tubing popped off several times and the spouse has to place it back on and no one checks to make sure it was done correctly."

- "He [spouse] reported the hose fell on the floor last week and the attending nurse/RT (he was unable to identify) picked it up off the floor and reattached it without cleaning it."

- "He [spouse] said his wife is scared and feels unsafe."

The Director of Quality Management was interviewed on 9/05/18, beginning at 2:03 PM, and the grievance response letter was reviewed in her presence. She confirmed the written grievance response to the patient did not address all the identified issues. Additional grievance response letters were requested from the Director of Quality Management, however, she stated there "were no others." She stated she had not kept records of any other grievance response letters.

The hospital failed to provide written grievance resolutions which included all results of the grievance resolution.

Based on medical record review, observation, incident report review, personnel file review, hospital policy review, quality improvement document review, and staff interview it was determined the hospital failed to ensure care was provided in a safe setting. This directly impacted the safety of 1 of 1 patient (Patient #2) who experienced cardiopulmonary arrest and whose record was reviewed. This resulted in fragmented patient care, poor clinical outcomes, and had the potential to affect all patients receiving care at the hospital. Findings include:

The hospital failed to ensure patients received care in a safe setting. Examples include:

1. Patient #2 was a 32 year old female who was admitted to the hospital on 6/08/18, with a diagnosis of acute respiratory failure. Additional diagnoses included confusion, high fall risk, and intracranial hemorrhage. She was scheduled to discharge to a SNF on 6/29/18; however she expired in the hospital on 6/28/18.

A hospital policy "Fall Prevention & Management Program," reviewed March 2018, stated "High Risk Fall Prevention Interventions...Bed and chair alarm...Seat belt alarm...Low Bed with defined perimeter mattress/nonskid floor mat...Alarms at exits...Nurse Call and communication systems..."

A hospital policy "Clinical Alarms," reviewed March 2018, stated:

- "Clinical staff will manually set off alarms during operational assessment of all medical devices/equipment to assure proper functioning of the equipment and associated alarms prior to use on a patient."

- "Clinical staff will immediately report any device malfunctions or concerns to the Plant Operations and/or Biomedical Staff. Tag and remove the device from operation according to the hospital's policies and procedures until it has been evaluated."

Patient #2's medical record included a "Nursing ICU Shift Assessment-Flowsheet," dated 6/27/18 at 9:07 PM, signed by RN D, which stated "Morse Fall Risk...55.0" and "45 or Greater = High Fall Risk...Action-Implement High Risk Fall Precautions."

Patient #2's medical record included a "Patient Care Notes," dated 6/27/18 at 9:07 PM, signed by RN D, which stated "bed alarm on."

Patient #2's medical record included a "Patient Care Notes," dated 6/28/18 at 12:14 AM, signed by RN D, which stated "bed alarm on."

Patient #2's medical record included a "Patient Care Notes," dated 6/28/18 at 4:00 AM, signed by RN D, which stated "bed alarm on."

Patient #2's medical record included a "Nursing ICU Shift Assessment-Flowsheet," dated 6/28/18 at 9:30 AM, signed by RN C, which stated "Morse Fall Risk...55.0" and "45 or Greater = High Fall Risk...Action-Implement High Risk Fall Precautions."

Patient #2's medical record included a "Patient Care Notes," dated 6/28/18 at 9:45 AM, signed by RN C, which stated "bed alarm on."

Patient #2's medical record included a "INTERDISCIPLINARY TEAM MEETING/CARE CONFERENCE" note, dated 6/28/18, signed by Patient #2's physician, which stated Patient #2 had "Safety Issues," "Fall Risk," "Alteration in Mobility," and "Orientation x 2."

Patient #2's medical record included a "Nursing LTAC ADL Flowsheet," dated 6/28/18 at 12:15 PM, signed by RN C, which stated "Bed exit alarm in use."

Patient #2's medical record included a "CODE BLUE RECORD," dated 6/28/18 at 6:03 PM, signed by the NP, which stated "patient was found face down on the floor. patient [sic] was rolled over and CPR started." The form stated CPR was stopped at 6:26 PM, and Patient #2 was pronounced dead. Additionally, the form stated "Events Leading up to Code...in bed 30 min with bed alarm on prior to finding on floor face down."

Patient #2's medical record included a "Patient Care Notes," dated 6/28/18 at 8:12 PM, signed by RN C, which stated "Patient was discovered laying on left side prone position on left side of the bed approximately 1805. Tube feeding still attached and running. Foley intact. Patient rolled onto back, discovered not breathing or palpable pulse. Code called and compressions initiated immediately by discovering nurse."

An RCA, provided by the Director of Quality Management, titled "A Framework for a Root Cause Analysis and Action Plan In Response to a Sentinel Event or Had the Potential For," undated, and unsigned, stated:

- "This patient was admitted to VHBoise [sic] on 06/08/2018 S/P Cranial Bleed.

The patient struggled with each level of improvement but after 20 plus days of intense respiratory/pulmonary and work with therapies the patient was nearly ready for referral to acute rehab services.

On 06/28/2018 Case Management had one accepting facility and one potentially pending. The patient had been ambulating with therapies in the afternoon. At approximately 18:00 on the 28th the patient was found face down on the floor next to the bed in full arrest.

She was turned and CPR was immediately initiated. Airwary was patent as she still had her trach in. The resuscitation efforts were unsuccessful and the code was called at 18:26."

The RCA did not identify, analyze, or investigate Patient #2's fall directly preceeding her death. The potentially faulty hospital bed and alarm system used for Patient #2 was not identified, analyzed, or investigated.

On 8/31/18 at approximately 8:30 AM, the CEO provided 2 HR investigative notes regarding Patient #2's death, however, these notes were not included in the hospital's RCA. The first HR investigative note, dated 6/30/18, was a recalled series of events by RN C to the Regional HR Director, which stated:

- "4:00 PM - Went in for a reassessment. Patient [Patient #2] was fidgety and trying to get out of bed. [RN C] and [CNA A] raised the right lower side rail up and double checked to make sure the bed alarm was on. It was and she knew it was working because it had sounded earlier in the day."

- "5:00 PM - [CNA A] and CCO repositioned patient."

- "6:05 PM - [RN C] went into [room number] to get I's and O's and found patient unresponsive, facedown on the floor on the left side of the bed. She could not find a pulse, so he [sic] called a 'code' and started compressions. The left side rails on the bed were still up, she [Patient #2] was still connected to her tube feeding and the tele box. The bed alarm was not going off. RN C did not know how long this patient had been on the floor."

The second HR investigative note, dated 7/03/18, was a recalled series of events by CNA A to the Regional HR Director, which stated "Around 4:00 PM, [CNA A] and [RN C] went into [room number] and the patient [Patient #2] was trying to get out of bed. They put the right railing up (alternating side railings) and double checked to make sure the bed alarm was working."

The Director of Quality Management was interviewed on 8/31/18, beginning at 10:16 AM, and Patient #2's RCA was reviewed in her presence. She confirmed Patient #2's potentially faulty hospital equipment and fall were not identified, analyzed, or investigated as part of the hospital's RCA. The Director of Quality Management stated Patient #2's fall and potentially faulty hospital equipment should have been investigated.

The HR Regional Director was interviewed on 8/31/18 at 11:41 AM. When asked if she was part of the RCA regarding Patient #2's death, she stated no. The HR Regional Director stated she did not share information with RCAs unless requested.

The Medical Director, and Patient #2's physician, was interviewed on 8/31/18, beginning at 2:46 PM, and Patient #2's RCA was reviewed in his presence. He stated he was not asked to be part of Patient #2's RCA and stated he believed he should be involved. The Medical Director stated all medical records of patients who expired in the hospital would be sent for peer review. He stated Patient #2's medical record had not been sent to peer review yet.

CNA A was interviewed on 9/01/18, beginning at 9:20 AM, and Patient #2's RCA and medical record was reviewed in his presence. He stated Patient #2 tried to get out of bed "a few times that shift" and "bed alarm was on." CNA A stated he was unsure why Patient #2's bed and/or bed alarm was not working.

RN C was interviewed on 9/04/18, beginning at 10:31 AM, and Patient #2's RCA and medical record was reviewed in her presence. She stated Patient #2 attempted to get out of bed during her shift, was difficult to reorient, and would try to "get up." RN C stated Patient #2's bed alarm was on. She stated Patient #2's bed was not given to Biomedical Services to be inspected.

The NP, who ran Patient #2's code blue on 6/28/18, was interviewed on 9/04/18, beginning at 11:12 AM. He stated he was not a part of Patient #2's RCA. When asked if he had ever been asked to participate in a hospital RCA, the NP stated no.

The Director of Plant Operations was interviewed on 9/05/18, beginning at 8:30 AM. When asked if Patient #2's potentially faulty bed/bed alarm was turned over to him or to Biomedical Services, he stated no. The Director of Plant Operations stated he did not participate in Patient #2's RCA.

An incident report regarding Patient #2's death, updated 7/18/18, stated "RCA completed, scored 5 awaiting case closure by the Coroner's Office to obtain the outcome of Cause of Death."

The CEO was interviewed on 9/05/18, beginning at 4:37 PM. She confirmed Patient #2's RCA was not complete and did not identify her fall and hospital equipment issues.

The hospital investigation following Patient #2's death failed to identify, analyze, and investigate her fall, and potentially faulty hospital equipment.

2. Hospital staff did not follow ACLS guidelines during Patient #2's CPR.

The NP who ran Patient #2's code blue on 6/28/18, was interviewed on 9/04/18, beginning at 11:12 AM. He stated he responded to the code blue alert at 6:03 PM and, when he arrived, CPR was already in progress. The NP stated Patient #2 had no pulse and "was in PEA." He stated Patient #2 did not have a heart rhythm for the duration of code blue and expired at 6:26 PM.

The NP's personnel file was reviewed on 9/05/18, beginning at 12:30 PM, and current ACLS certification was confirmed.

The ACLS Medical Training website, accessed 9/12/18, included the following algorithm for PEA:

- "Continue CPR; Airway; Oxygen; Connect monitors"

- "Epinephrine 1 mg ASAP and every 3 - 5 minutes"

- "Evaluate rhythm..."

- "Evaluate and treat reversible causes"

Patient #2's medical record included a "CODE BLUE RECORD," dated 6/28/18, signed by the NP. The form documented a series of events not covered under the ACLS PEA algorithm:

a. From start of CPR at 6:03 PM, to pronouncement of death at 6:26 PM, Patient #2 did not have a "Monitored Rhythm" or identified cardiac waveform.

b. From start of CPR at 6:03 PM, to pronouncement of death at 6:26 PM, Patient #2 did not have a monitored oxygen saturation level. The form documented "O2 @ flushed % via trach." It was unclear what percent of supplemental oxygen, or the flow rate, "flushed" was.

c. Patient #2 was manually defibrillated (the stopping of fibrillation of the heart by administering a controlled electric shock in order to allow restoration of the normal rhythm) at 6:03 PM, 6:05 PM, 6:07 PM, 6:09 PM, 6:11 PM, 6:13 PM, 6:14 PM, 6:16 PM, 6:18 PM, 6:20 PM, 6:22 PM, and 6:24 PM. The form did not indicate what joules were used for defibrillation.

d. Patient #2 was defibrillated via an AED at 6:07 PM, 6:09 PM, 6:11 PM, 6:13 PM, 6:14 PM, 6:16 PM, 6:18 PM, 6:20 PM, 6:22 PM, and 6:24 PM. The form did not indicate what joules were used for defibrillation.

e. From start of CPR at 6:03 PM, to pronouncement of death at 6:26 PM, Patient #2 did not receive initial, or subsequent, Epinephrine 1 mg IV push.

f. Patient #2 received an unknown infusion [drip] quantity of Epinephrine at 6:10 PM (7 minutes after the initiation of CPR), 6:13 PM, 6:18 PM, and 6:23 PM.

It was unclear if these CPR interventions occurred as documented, or if they were recorded in error.

The CEO was interviewed on 8/31/18, beginning at 1:56 PM, and Patient #2's code blue form was reviewed in her presence. When asked if staff retained Patient #2's cardiac waveforms, printed by the crash-cart defibrillator used during her CPR, the CEO stated "staff cannot locate them."

The VP of Clinical Development and Operations was interviewed on 9/04/18, beginning at 2:00 PM. She stated "post code huddle documentation was not done" for Patient #2.

The Director of Quality Management was interviewed on 9/04/18, beginning at 2:17 PM, and Patient #2's code blue form was reviewed in her presence. She confirmed Patient #2's documented CPR did not follow ACLS guidelines. The Director of Quality Management stated Patient #2's code blue form was not reviewed for accuracy or appropriateness.

Hospital staff did not follow ACLS guidelines during Patient #2's CPR.

3. The hospital provided a form titled "LTACH EDUCATION PLAN 2018," undated. The section titled "EDUCATION PLAN 2018" included a list of trainings to happen each month; including "Mock Code/RRT." This training was marked with an asterisk that denoted "Mandatory Education."

The last documented mock code was November 2017.

The CEO was interviewed on 8/31/18 beginning at 1:00 PM, and stated her expectation was for mock codes to be done 2 times a month.

The CCO was interviewed on 8/31/18 beginning at 9:30 AM, and stated her expectation is for mock codes to be done at least every 90 days. She did not remember the last time the facility performed a mock code.

The VP of Clinical Development and Operations was interviewed 9/05/18 beginning at 4:20 PM. She stated the "Mandatory Education" was a suggestion and each hospital created their own education plan for the year and sent it to corporate. When asked if the hospital had submitted an education plan for 2018 to corporate for approval she stated no. The VP of Clinical Development and Operations confirmed the last documented mock code was completed in November 2017.

The hospital failed to follow their education plan.

4. Patient #2's death record did not include accurate documentation.

Patient #2's medical record included a "Record of Death," dated 6/30/18. The form included 2 main sections: "NOTIFICATION" and "EYE/TISSUE/ORGAN DONATION." These 2 sections appeared to be completed by 2 different sets of handwriting. The bottom of the form included a section titled "TO BE COMPLETED BY HOSPITAL PERSONNEL." This section included the printed name of HS B next to "Funeral Home called by" and "Body of Decedent released by" dated 6/29/18 at 2:20 AM. Additionally, the bottom of the form included an illegible signature, dated 6/30/18 at 8:00 AM.

HS B was interviewed on 9/04/18, beginning at 3:19 PM, and Patient #2's death record was reviewed in his presence. When asked if he filled out any portions of the form, he stated no. HS B stated he was not working on 6/29/18 at 2:20 AM. He stated he did not recognize either of the 2 handwritings on the form, nor was he able to identify the unknown signature at the bottom of the form. HS B confirmed Patient #'2 death record was not accurate.

Patient #2's death record did not include accurate documentation.

5. A hospital Telemetry Monitor Technician was unable to perform job duties.

A hospital policy "Clinical Alarms," reviewed March 2018, stated:

- "All staff that utilize or maintain equipment/devices with clinical alarm systems will be properly oriented to the equipment/device, the alarm and trained on its use."

- "All staff using and/or maintaining medical equipment/devices with related alarm systems must be assessed and proven competent to operate the equipment/device and manage its associated alarm mechanism prior to use of that equipment/device."

- "For all equipment/devices with clinical alarms, staff competency assessment will be conducted prior to initial use of equipment/device and annually thereafter."

This policy was not followed.

An observation of the hospital's ICU was conducted with the VP of Licensing and Accreditation on 9/04/18, beginning at 11:40 AM, and MT B was observed executing her job duties at that time. MT B was located at the ICU nurses station and was responsible for monitoring patients' ECG waveforms remotely. During the observation, 9 of 13 patients on MT B's computer screen displayed "ECG ALARMS OFF." When asked why these 9 patients had their alarms turned off, MT B stated she did not know and "I'm new to this; I guess I need education." When asked how long she had been performing the duties of a Telemetry Monitor Technician, MT B stated "3 weeks."

MT B's personnel file was reviewed on 9/04/18, beginning at 1:30 PM. MT B had a signed job competency; however, it was dated 9/02/18; 3 days after the start of the survey and several weeks after performing her job duties as a Telemetry Monitor Technician. MT B's personnel file did not include a documented orientation to her job duties.

MT B was interviewed on 9/05/18, beginning at 9:26 AM. She stated she was new to her role as a Telemetry Monitor Technician and had been "on my own for about 3 weeks." MT B stated she had no previous experience in telemetry monitoring or education prior to accepting her new role. She confirmed her competency was performed and documented after the start of the survey.

A hospital Telemetry Monitor Technician was unable to perform job duties.



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6. The hospital provided a form titled "LTACH EDUCATION PLAN 2018," undated. It stated "New nursing and clinical employees will continue their orientation to each specific department ... An orientation checklist will be completed with a goal to sign off the initial core competencies within the first 90 days of hire." This was not followed. Examples include:

The personnel file of CNA A was requested. CNA A's personnel file included a date of hire 2/16/18. The file included a skills checklist titled "CORE COMPETENCY / DEMONSTRATION CNA Skills Checklist." The checklist included multiple skills that were signed off as "met" by the educator, and was completed on 8/30/18. There was no other documentation CNA A had completed his skills checklist prior to 8/30/18.

CNA A's personnel file also included a form titled "CORE COMPETENCY / DEMONSTRATION NURSING ASSISTANT." The form included multiple components, some examples included:

- Treats patient with respect.
- Involves patient in care decisions.
- Communicated effectively with patient.
- Understands the hospital's patient complaint grievance process.
- Follows safe hospital practices and protective services.
- Performs job ethically.
- Restraints.

The form documented the components were signed off by the Educator on 8/30/18. There was no other documentation these components were completed prior to 8/30/18.

During an interview with the VP of Clinical Development and Operations on 9/05/18 beginning at 4:30 PM, she confirmed CNA A's skills checklist and core competency were completed on 8/30/18, 6 months after his date of hire. She stated she contacted CNA A and he stated he must have lost the original checklist and competency form. The VP of Clinical Development and Operations stated the expectation is the CNA skills checklist and core competency should be completed and signed off within 90 days of date of hire. She confirmed CNA A did not have a documented skills checklist or core competency prior to 8/30/18.

The Hospital failed to ensure CNA A was competent in his job duties prior to 8/30/18.

Based on hospital policy review, Idaho Statutes review, grievance log review, and staff interview, it was determined the hospital failed to ensure patients were free from abuse or harassment for 2 of 2 grievances reviewed which documented potential abuse. This had the potential for unsafe conditions for all patients receiving care at the hospital. Findings include:

"IDAHO STATUTES TITLE 39 HEALTH AND SAFETY CHAPTER 53 ADULT ABUSE, NEGLECT AND EXPLOITATION ACT," updated 7/01/18, states "39-5303. Duty to report cases of abuse, neglect or exploitation of vulnerable adults. (1) Any physician, nurse, employee of a public or private health facility, or a state licensed or certified residential facility serving vulnerable adults, medical examiner, dentist, osteopath, optometrist, chiropractor, podiatrist, social worker, police officer, pharmacist, physical therapist, or home care worker who has reasonable cause to believe that a vulnerable adult is being or has been abused, neglected or exploited shall immediately report such information to the commission. Provided however, that nursing facilities defined in section 39-1301(b), Idaho Code, and employees of such facilities shall make reports required under this chapter to the department. When there is reasonable cause to believe that abuse or sexual assault has resulted in death or serious physical injury jeopardizing the life, health or safety of a vulnerable adult, any person required to report under this section shall also report such information within four (4) hours to the appropriate law enforcement agency." This Statute was not followed.

A hospital policy "Suspected Patient Abuse/Neglect," reviewed March 2018, stated:

- "The Hospital maintains a strict policy to prevent or respond to allegations of abuse, neglect or mistreatment, including prompt reporting of any alleged abuse incident to hospital leaders and applicable state agencies."

- "Patient Abuse, Neglect, and/or Mistreatment is defined as any incident of physical, sexual, or verbal abuse, neglect, and/or mistreatment that is reported by patient or family; or is witnessed, reported, or suspected by an employee."

- "2. If the suspected abuse, neglect, mistreatment and/or exploitation involves an employee, the Hospital Chief Executive Officer will determine the action to be taken based on the investigation performed by appropriate Administration/Management. The employee may be suspended during the investigation, and if abuse is confirmed, termination of employment will result."

- "4. All investigation and resulting action documentation will be maintained in the Administrative office." This policy was not followed.

A second hospital policy "Reporting Issues of Concern," reviewed March 2018, stated "As required by state-specific laws, issues of non-compliance must be reported to appropriate state agencies. In certain states, health-care employees are designated as 'mandated reporters'. This designation requires that employees who have knowledge of or observed known or suspected abuse incidents must report such an event to an outside agency. The report, either written or oral, must be made as required by state law." This policy was not followed.

The hospital's "Complaint/Grievance Log 2018," included 2 potential patient abuse grievances:

1. Incident 15584, dated 1/29/18, stated "The patient told the CCO while writing on her whiteboard that 'My Nurse Hit Me' and then walks by giving me dirty looks. The patient stated the she [sic] couldn't remember when it happened or where the event took place. No obvious signs of injury. Patient is somewhat confused with a history of CVA."

The investigation of incident 15584, dated 2/20/18, stated "The communication with the CCO occurred at 15:00 on 01/29/18. Spoke with the nurse involved who outlined everything that had been happening for the first 3 hours of the shift. CCO spoke to the nursing supervisors and made arrangements for someone else to be assigned to [patient name]."

The investigation did not include which nurse was spoken to, when, about what, or what conclusions were made. The investigation did not identify which nursing supervisors were interviewed, when, about what, or what conclusions were made. The investigation did not include the date and time the nurse was removed from the patient's care and what steps were taken to ensure the patient was kept safe. The investigation did not include an interview with the patient and, subsequently, what her concerns were. The investigation did not include a written grievance response letter to the patient regarding her concerns. It could not be determined what steps the hospital took to ensure similar issues did not occur in the future.

2. Incident 15277, dated 3/21/17, stated "Patient C/O nurse putting head between two pillows and leaving him, C.N.A. came in and 'saved' him. Patient told wife to call the State and she refused."

The investigation of incident 15277, dated 4/18/17, stated "CEO & DBD spoke with the patient and the wife. There is a history with the patient of confusion particularly at night and all was resolved at that point."

The investigation did not include if the nurse in question was spoken to, when, about what, and what conclusions were made. The investigation did not include if the nurse in question was removed from the patient's care and what steps were taken to ensure the patient was kept safe. The investigation did not include an interview with the patient, patient's spouse, or what their concerns were. The investigation did not resolve why the State was not contacted when requested by the patient and identified by hospital staff. The investigation did not include a written grievance response letter to the patient regarding his concerns. It could not be determined what steps the hospital took to ensure similar issues did not occur in the future.

The Director of Quality Management was interviewed on 9/05/18, beginning at 2:03 PM, and the hospital's grievance log was reviewed in her presence. She stated she had not previously identified the 2 patient incidents as potential abuse and confirmed the hospital did not follow State statutes and/or hospital policy to ensure patients were free from abuse and kept safe.

The hospital failed to ensure patients were free from abuse or harassment.

Based on staff interview and review of quality documents, it was determined the hospital failed to analyze 3 of 12 adverse patient events and recommend preventive actions. This resluted in incomplete information with which to make decisions regarding care systems. Findings include:

1. The form "CODE BLUE/RAPID RESPONSE MONITORING AND EVALUATION," not dated, stated a "Code" was started on 2/10/18 at 5:50 PM. The form did not state specifically what happened. It listed the events leading up to the code and who responded. It listed personnel involved and stated the time the "Resuscitation Event" ended. The form did not state what took place during the event. The form did not include an analysis of the event nor did it include a determination of how staff performed during the event and whether resources were sufficient to respond to the event effectively.

The Director of Quality Management was interviewed on 9/05/18 beginning at 9:00 AM. She stated an analysis of the event was not documented.

2. The form "CODE BLUE/RAPID RESPONSE MONITORING AND EVALUATION," not dated, stated a "Code" was started on 8/07/18 at 10:14 PM. The form was blank.

Another form, titled "Rapid Response Team Care Record," undated, listed the events leading up to the event. It did not list personnel involved. The form did not state what took place during the event. The form did not include an analysis of the event nor did it include a determination of how staff performed during the event and whether resources were sufficient to respond to the event effectively.

The Director of Quality Management was interviewed on 9/05/18 beginning at 9:00 AM. She stated an analysis of the event was not documented.

3. Refer to A144 as it relates to the failure of the hospital to thoroughly analyze the causes of a patient death under unusual circumstances and implement preventive actions.

Based on staff interviews, review of hospital documents, policies, and job descriptions, it was determined the hospital failed to ensure nursing services were organized under the authority of a director of nursing services responsible for nursing staff and care provided in the hospital. This failure had the potential negatively impact the quality of care provided to patients. Findings include:

The hospital's organizational chart was requested and received on 8/30/18 at 12:20 PM. It included the position of CCO, who reported to the CEO. Five departments were listed as reporting to the CCO: Laboratory, Radiology, Rehabilitation, Nursing, and Infection Control/Education. The Laboratory, Radiology, Rehabilitation, and Infection Control/Education departments each included the name of the department manager or supervisor. The Nursing department, which included the RN, LPN, CNA, and Unit Clerk positions, did not include the name of a department manager.

The Division President for the Mid-Mountain Region was listed directly under the Governing Board on the hospital's organization chart. He was a corporate vice-president who lived in another state. He was interviewed by telephone on 9/05/18 beginning at 11:00 AM. He stated he was Chairman of the Board for the hospital.

The Division President stated the hospital did not have a DON and said it was not the hospital's model to employ a DON. He stated the hospital had a Chief Clinical Officer who was a respiratory therapist. He stated she had oversight of the nursing department of the hospital.

The hospital's policy, "Plan for Provision of Care," effective 3/2018, stated "The Department of Nursing is a distinct department. The Chief Clinical Officer ultimately oversees all nursing related issues."

The job description titled "Chief Clinical Officer - LTAC," revised May 2017, was reviewed. It stated "MINIMUM QUALIFICATIONS: Bachelor of Science Degree in Nursing required. Master's Degree in Health Administration, Nursing or related field required. Five (5) years experience in a Nursing Management position supervising the delivery of patient care required. Current, valid, and active license to practice as a Registered Nurse in the state of employment required." The job description included a handwritten notation, next to "MINIMUM QUALIFICATIONS," that stated "Corporate approved RRT [Registered Respiratory Therapist] degree/license in place of Nursing license." The handwritten notation was signed by the Director of Human Resources. The notation was not dated. The job description was signed by the current CCO, an RT, on 6/03/18.

The job descriptions for the positions of Nurse Supervisor, Registered Nurse, CNA, Telemetry Monitor Tech, and Unit Secretary/Unit Clerk each included "Position Reports to: Chief Clinical Officer/Chief Nursing Officer/Nurse Manager." The hospital's organizational chart did not include the positions Chief Nursing Officer or Nurse Manager. Nursing staff job descriptions directed the nursing staff to report to the CCO, an RT.

During an interview on 9/04/18 at 9:40 AM, CNA A was asked to identify his supervisor. He named the CCO, an RT, as his supervisor.

During an interview on 9/04/18 at 12:00 PM, HS B was asked to identify his supervisor. He named the CCO, an RT, as his supervisor.

On 8/31/18 at 8:48 AM, an RN was observed administering medications to a patient. She was asked to identify her supervisor. She named the CCO, an RT, as her supervisor.

On 9/05/18 at 3:34 PM, LPN B was interviewed in the presence of the CCO. When asked to identify her supervisor, she stated she was not sure. When asked who she would go to to request time off of work, she stated she was not sure. The CCO stated she was responsible for approving requests for time off from nursing staff.

The hospital failed to ensure an RN was responsible for the operation of nursing services.

Based on staff interview, review of personnel files and hospital policies, it was determined the hospital failed to ensure nursing care provided by LPNs was evaluated and supervised by an RN, for 2 of 2 LPNs who were interviewed or whose personnel file were reviewed. This had the potential to result in nursing care that failed to comply with accepted standards of nursing practice and/or hospital policy, and unmet patient needs. Findings include:

The hospital's policy, "Plan for Provision of Care," effective 3/2018, stated "A registered nurse will define, direct, supervise, and evaluate the nursing care of each patient...The Licensed Practical Nurse works under the direct supervision of an RN and assists in data collection, planning, implementation and evaluation of patient care."

1. The personnel file of LPN A was requested. Included in LPN A's personnel file was a form titled "CORE COMPETENCY / DEMONSTRATION." The form included a checklist of skills LPN A completed and each of the skills was documented as "Met" and initialed by an LPN . There was no documentation LPN A's skills were observed and signed off by an RN.

2. LPN B was interviewed on 9/05/18 at 3:34 PM. She stated she had been working at the hospital for 3 weeks. She stated she oriented with another LPN for 2 weeks. LPN B stated at the end of her 2 week orientation the other LPN observed her providing care and signed her competency checklist. She stated she was approved to work independently. LPN B stated an RN had not observed her providing care. She stated she did not receive RN supervision on a regular basis, but would approach an RN on the unit if her patient needed nursing services she could not provide as an LPN.

The VP of Clinical Development and Operations was interviewed on 9/05/18, beginning at 4:30 PM. She confirmed LPN A's skills checklist was signed by an LPN. She stated the expectation is the LPN skills checklist should be completed and signed by an RN.

The hospital failed to ensure nursing care provided by LPNs was supervised by an RN.

Based on staff interview, review of contracts, documents, policies, and personnel records, it was determined the hospital failed to ensure orientation and training of non-employee contracted nursing personnel. This had the potential for poor patient outcomes due to lack of orientation and training of contracted nurses. Findings include:

The hospital's policy, "Volunteer, Student Observers, Interns, Externs, Per Diem, and Contracted Services," revised 3/12/18, stated "Contracted Services...Orientation
a. All contracted personnel are required to complete the Hospital orientation packet to ensure a through [sic] understanding of expectations, hospital policies, safety and infections.
b. Department orientation will address patient care issues and departmental policies and procedures.
c. The Department Director remains responsible for the oversight of the contracted personnel."

The hospital's "Daily Staffing Assignment" sheets for 7 days, from 8/30/18 to 9/05/18, were reviewed for the number of RNs on the night shift (7:00 PM to 7:30 AM) who were hospital employees verses contracted staff. On 6 of the 7 nights, the RN supervisor was a contracted RN. Ten of 40 RN night shifts, or 25%, were completed by contracted RN staff.

A contract titled "Travel Personnel Staffing Agreement," signed by the hospital's CEO on 1/26/17, stated "Hospital shall orientate all Nurses to Hospital's internal policies and practices. Such orientation shall include information necessary to orientate each Nurse to the particular unit he/she has been assigned."

The personnel files of 2 RNs contracted through the travel agency were reviewed, with start dates of 4/30/18 and 5/28/18. They did not include documentation of an orientation to the hospital's policies and procedure, or a department orientation.

A contract titled "STAFFING AGREEMENT," signed by the hospital's CEO on 6/17/16, stated "Facility shall provide such orientation and non-job specific training (such as training regarding Facility's employment policies) as is reasonably required by facility."

The personnel files of 2 RNs contracted through the staffing agency were reviewed, with start dates of 5/09/17 and 12/07/17. They did not include documentation of an orientation to the hospital's policies and procedure, or a department orientation.

During an interview on 9/05/18 at 4:05 PM, the VP of Clinical Development and Operations reviewed the personnel files of the 4 contracted RNs. She confirmed the 4 files did not include documentation of an orientation to the hospital's policies and procedure, or a department orientation.

The hospital failed to ensure RNs working in the hospital under contract received education on the hospital's policies and procedures, or orientation to the department.

Based on staff interview and review of patient records, hospital policy, and hospital incident report, it was determined the hospital failed to ensure medications were administered in accordance with accepted standards of practice and hospital policy for 1 of 8 patients (Patient #2) whose records were reviewed. This resulted in the administration of a medication ordered PO and given IV. Findings include:

Patient #2 was a 32 year old female who was admitted to the hospital on 6/08/18, with a diagnosis of acute respiratory failure. Additional diagnoses included confusion, high fall risk, and intracranial hemorrhage. She was scheduled to be discharged to a SNF on 6/29/18, however she expired in the hospital on 6/28/18.

The hospital's policy, "Administration of Medications," effective 6/2013, stated: "The six 'rights' of administering medications will be followed with each medication administration:
1. Right patient.
2. Right drug.
3. Right dose.
4. Right route.
5. Right time.
6. Right documentation."

The facility failed to follow their policy.

Patient #2's medical record included an order for Vancomycin 125 mg by mouth every 6 hours. The medical record documented that Vancomycin was given on 6/08/18 at 11:19 PM. The Vancomycin was documented in Patient #2's MAR as given by the correct route. However, there was an incident report that documented a medication error on 6/08/18 related to Patient #2's oral Vancomycin.

There was no additional documentation of the medication error in Patient #2's medical record.

An incident report was reviewed for Patient #2 that documented a medication error on 6/08/18. The incident report documented the oral Vancomycin ordered for Patient #2 was unavailable and that the on-call pharmacist was called for mixing instructions. The medication was mixed by the RN per instructions from the on-call pharmacist and Patient #2's nurse gave the Vancomycin IV push instead of PO as ordered.

The Director of Pharmacy was interviewed on 8/31/18, beginning at 10:55 AM, and Patient #2's incident report was reviewed in her presence. She stated the on-call pharmacist should have come in to the hospital to mix the Vancomycin.

The Director of Pharmacy was interviewed on 9/06/18 beginning at 1:30 PM, and confirmed Patient #2 received the Vancomycin 125 mg IV push instead of PO as ordered. She stated the RN who administered the Vancomycin had been reeducated on medication administration.

The hospital provided an RCA that identified the medication error. The RCA documented the nurse and on-call pharmacist were provided reeducation on medication mixing and administration.

Patient #2 did not receive her medication as ordered.